United Healthcare Incident-to Billing
- In December of 2020, UHC announced that for their commercial plans, APRNs who had their own NPI would be required to be credentialed and directly bill for their services even when performed incident-to, with reimbursement for such services at 85% of the contracted rate. This policy went into effect May 1, 2021. Incident-to services allow APPs to treat patients under the direct supervision of a physician without being required to be contracted with the health plan and receive reimbursement at 100% of the contracted rate. For several months HCMS and the TMA urged UHC to reconsider this policy as it would be disruptive to physician practices and patient care. As a result of these efforts, UHC reversed this restriction on incident-to billing in two policy notices (Advanced Practice Health Care Provider Policy, Professional
#2021R5009B and the Services Incident-to a Supervising Health Care Provider Policy, Professional
#2021R5025A) and will honor incident-to billing when the incident-to requirements are met. Such claims will be reimbursed at 100% of the applicable fee schedule. These new policies became effective 8/1/2021.
BCBSTX Incident-to Billing
In a 1/19/2021 policy statement
, BCBSTX indicated they would no longer pay for incident-to services (identified by the SA modifier), and instead would require board-certified physician assistants (PAs) and nurse practitioners (NPs) to contract with the health plan in order to bill directly for their services under their own NPI numbers. TMA and HCMS communicated to BCBSTX our concerns with this policy as it would eliminate the practice of incident-to billing utilized by many practices adversely affecting patient care, established practice work processes, and cash flow (payments for claims billed using an non-physician practitioner’s NPI number are typically paid at 85% of the physician’s contracted rate). As a result, on 5/12/21 BCBSTX published a reversal of this policy
stating the policy will not be implemented and there are no plans to implement such a policy in the future.
United Healthcare (UHC) Optum Pay
- In January 2021 physicians began experiencing significant problems with Optum Pay and were unable to obtain readable remittances or perform other revenue cycle functions available to them prior to the implementation of a new Optum Pay premium paid subscription service. UHC had communicated to us that the main functions needed to conduct business with UHC would remain in the free version and the paid version would provide enhanced functionality. However, upon rollout, the functionality of the free version was greatly reduced, and physicians reported to HCMS that they were experiencing several issues. They were unable to obtain readable remittances or perform other revenue cycle functions available to them prior to the implementation of the Optum Pay premium paid subscription service. UHC had communicated to us prior to implementation that the main elements needed to conduct business with UHC would remain in the free version and the paid version would simply provide enhanced functionality. However, when the paid version went live, many of the services practices once had access to moved to the premium service, and the basic functions that were to remain in the free version were no longer available causing significant business interruptions, the need for additional and complicated work-arounds, payment and banking reconciliation disruptions, and other revenue cycle management difficulties. HCMS reached out to UHC on several occasions to report these issues and provided examples of problems experienced by physicians not only in Harris County, but across the nation. As a result of our efforts and those of other organizations, UHC restored access to the essential functions in the free version of Optum Pay allowing physicians to continue to manage their UHC business without having to pay for the premium service.
United Healthcare (UHC) malpractice liability limits increase
- In December 2020 HCMS learned UHC would be requiring an increase in liability limits from $100,000/$300,000 to $1 million/3 million which was set to take effect March 1, 2021. HCMS reached out to UHC and advised them that Texas enacted tort reform in 2003 (see below item) to limit frivolous lawsuits and placed a cap on noneconomic damages at $250,000. As such, liability limits at $1 million/3 million were unnecessary in Texas and caused an economic burden to our physicians. As a result of these efforts, UHC indefinitely postponed
the requirement. HCMS continues to monitor any changes in liability limits by payors to ensure they are appropriate for our physicians.
Newborn Screens Underpayments
- Several physicians contacted HCMS regarding systematic underpayments for the state-mandated newborn screens by several commercial and Medicaid Managed Care payors. Each of these payors were contacted by HCMS and made aware of the underpayments in violation of state law
. Most of these payors were unaware such a law existed and based their reimbursement methodology on a percentage of billed charges. HCMS provided the applicable state regulations and other documentation that mandates that the reimbursement rate for newborn screens be equal to that provided by the Department of State Health Services
. As a result, these payors reprocessed claims for several physicians and updated their claims systems to reflect the correct reimbursement amount. Please report any underpayments for newborn screens to the HCMS Payment Assistance department at 713-524-4267 or firstname.lastname@example.org.
Wellcare Texan Plus CMS Complaint
– In January 2019 HCMS received a high number of complaints regarding Texan Plus and Wellcare. The migration of Texan Plus physicians to the Wellcare system failed, and as a result, the affected physicians could not access the portal, verify eligibility and benefits, obtain authorizations or referrals online or by phone, or conduct any business online. Payments to physicians were also delayed, incorrect, or denied, and seeing Texan Plus patients became difficult. Many physicians and patients had to cancel appointments and procedures until they received instructions from Wellcare. Unfortunately, the instructions they received were inconsistent and often incorrect. HCMS met with Wellcare leaders to discuss the issues and find a work-around until these physicians could be manually loaded into Wellcare’s system. Corrective action was slow despite several meetings with Houston market and corporate Wellcare leadership, and physicians as well as patients suffered. As a result, HCMS filed a complaint with the Atlanta CMS Regional Office to find resolution to the surfeit of problems that continue to effect physicians and their patients. We have had several discussions with CMS Atlanta office. HCMS will continue to assist physicians who have contacted us for help and will meet with Wellcare leadership frequently until these issues are resolved. If you are having any issues with Wellcare Texan Plus, please call HCMS at 713-524-4267 and ask for the Payment Assistance department.
– 2019 Texas Legislative Session – Passed SB 1742. Prior Authorization (utilization review) requirements have become increasingly burdensome and are adversely affecting patient care delaying procedures and needed medications or denying these services altogether. HCMS has been at the forefront to change the law in regard to the onerous prior authorization requirements imposed on physicians by payers through Congress and state legislators.
HCMS put forth a resolution to the 2018 TMA House of Delegates that physicians conducting utilization review medical necessity decisions must be a physician licensed in Texas and be of the same or similar specialty as the requesting physician. We were advised this resolution would be an uphill battle as there would be a great deal of push-back from payers. Nonetheless, HCMS worked with TMA lobby staff and general counsel to push through the 2019 Texas legislative session. SB 1742, which was signed into law by Governor Abbott in June 2019, with an effective date of Sept. 1, 2019, resulted in requiring that:
A Utilization Review Agent’s (URA) utilization review (UR) plan to be reviewed by a physician licensed to practice medicine in Texas and conducted in accordance with standards developed with input from appropriate health care providers and approved by a physician licensed to practice medicine in Texas.
A URA to conduct utilization review under the direction of a physician licensed to practice medicine in Texas.
Personnel employed by or under contract with a URA to perform UR to be appropriately trained and qualified and meet the requirements of the UR chapter and other applicable law, including applicable licensing requirements.
Modifies language regarding reviews of adverse determinations to permit an earlier same or similar specialty review at the 1st level appeal, rather than the 2nd level appeal.
The 2019 Texas legislative push to improve the prior authorization process for physicians is in the infancy stages. We will continue this effort by working with the new task force on prior authorization which was mandated by SB1742, and the new TMA Ad Hoc Committee on Prior Authorization.
The AMA conducted a survey to determine the effects of prior authorization on the healthcare industry: 2019 AMA Prior Authorization Survey.
Aetna TDI Complaint
– In late 2018, several physicians contacted HCMS regarding letters from Aetna informing them they were being deselected from 3 Aetna plans. As there was a fully-insured plan included, the deselection process from that plan violated the Texas Insurance Code, particularly sections 1301.0057 and 1301.0057, regarding physician termination. As such, HCMS filed a complaint with the Texas Department of Insurance (TDI) resulting in the removal of the fully-insured plans from the deselection notice. HCMS then met with Aetna representatives to better understand the criteria used to identify physicians for the systematic deselection. HCMS provided information that revealed that several of the physicians who contacted us did not meet that criteria. As such, Aetna reconsidered and pended or rescinded the deselections for several physicians.
Molina TDI Complaint
– In 2018, HCMS received an unusually high number of complaints from members regarding Molina Marketplace payment issues amounting to millions of dollars. Many practices, both large and small, had been attempting to resolve their issues as far back as 2015, to no avail. Many filed complaints with the Texas Department of Insurance (TDI), but after the lack of responsiveness from both Molina and TDI, physicians turned to HCMS for help.
HCMS reached out to its Molina contacts to try and resolve the issues, but like the membership, we too experienced a lack of response. Consequently, HCMS filed a TDI complaint against Molina in September 2018 on behalf of the affected practices. As a result, Molina’s CEO contacted HCMS to set up a meeting to discuss the issues. During the meeting, they committed to be the point of contact to resolve all issues with the assistance of their COO. Individual meetings were arranged at the HCMS offices in November 2018 with the Molina COO and all of the affected practices who had contacted HCMS for assistance. In February 2019, as a result of the HCMS complaint to TDI, TDI issued a Consent Order fining Molina $500,000 and requiring them to address their deficiencies.
To date we continue to meet with Molina on a regular basis to finalize the initial issue and address new ones as they are reported to us. If you are having any issues with Molina, please call HCMS at 713-524-4267 and ask for the Payment Advocacy Depart.
– 2003 Tort Reform – Passed HB 4 and Prop 12. This legislation was the result of years of effort by the medical communities, TMA, HCMS, TEXPAC, and others to create a fair and balanced judicial process in malpractice cases, and to de-incentivize claimants from filing frivolous lawsuits. This practice became so prevalent in the Texas Valley that physicians left the area en masse leaving a severe shortage of healthcare professionals to serve the community. Physicians began leaving statewide as the cost of medical liability for Texas physicians skyrocketed, making it too costly to practice medicine in Texas. These resulting shortages prompted the need for the legislation which placed a cap on noneconomic damages at $250,000 for all physician defendants and an additional cap of $250,000 for each of up to two medical care institutions. Other previous plaintiff-friendly procedural devices, such as forum shopping, were eliminated. It also required that there be a written medical report by a physician in the same or similar field as the one being sued, a report that clearly identifies the appropriate standard of care and how it was violated, and a delineation of specific damages resulting from the violation of the standard. The passage of HB 4 removed the hostile litigation environment in Texas and stopped the exodus of physicians in search of a more judicially fair and friendly one. In fact, the number of physicians coming to practice in Texas has increased dramatically since passage of the bill resulting in access to care in areas rural and border communities of Texas that was previously unavailable. Also, the number of liability carriers increased creating competition and better premium rates. Texas remains the premiere healthcare mecca in the country, and this legislation is partly responsible for this distinction. Note: Every Texas legislative session, Tort Reform is attacked by lobbies who are against this law. Defending Tort Reform is a priority for HCMS and TMA.
TxEver Death Certificate Registration System -The Texas Department of State Health Services created a new death certificate registration system, TxEVER, which went live Jan. 1, 2019. Since going live, it has been plagued with technical issues which have caused many physicians to exceed the 5-day window to file a death certificate. HCMS took action and met with representatives from the Texas Department of State Health Services to discuss the issues. As a result, HCMS created a list of FAQs specifically designed to address your concerns about the new system.
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